Nursing Elites

1. Following rectal surgery, a female client is very anxious about the pain she may experience during defecation. The nurse should collaborate with the healthcare provider to administer which type of medication?

• A. Bulk-forming agent
• B. Antianxiety agent
• C. Stool softener
• D. Stimulant cathartic

Correct answer: C

Rationale: After rectal surgery, a stool softener is the most appropriate medication to help prevent pain and straining during defecation. Stool softeners work by increasing the water content of the stool, making it easier to pass without discomfort. Bulk-forming agents (Choice A) help add mass to the stool but may not address the immediate post-operative discomfort. Antianxiety agents (Choice B) would address the anxiety but not the physical discomfort. Stimulant cathartics (Choice D) are not recommended after rectal surgery as they can cause cramping and increased bowel movements, potentially exacerbating pain.

2. The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?

• A. Increase wall suction while removing the suction catheter
• B. Instill 10 ml of sterile saline into the tracheostomy tube before applying continuous suction
• C. Suction the client’s oropharynx after tracheal suctioning
• D. Insert the suction catheter into the trachea, and apply intermittent suction with removal of the catheter

Correct answer: D

Rationale: When suctioning a tracheostomy tube, it is essential to insert the suction catheter into the trachea and apply intermittent suction with removal of the catheter. This technique helps prevent damage to the trachea and reduces discomfort for the client. Choice A is incorrect because increasing wall suction with the removal of the suction catheter can cause trauma to the tracheal mucosa. Choice B is incorrect because instilling saline into the tracheostomy tube before suctioning is not recommended as it can lead to complications. Choice C is incorrect as oropharyngeal suctioning should be done before tracheal suctioning to prevent the risk of aspiration.

3. The nurse is admitting a client from the post-anesthesia unit to the postoperative surgical care unit. Which intervention should the nurse implement first?

• A. Advance to clear liquids as tolerated
• B. Straight catheterization if unable to void
• C. Administer Cefazolin 1 gram IVPQ q6 hours
• D. Obtain a complete blood cell count (CBC) in the morning

Correct answer: B

Rationale: The correct answer is to perform straight catheterization if the client is unable to void. This action is essential to prevent urinary retention and its potential complications following anesthesia. Option A, advancing to clear liquids, is not the priority upon admission as the focus should be on urinary function first. Option C involves administering an antibiotic, which is important but not the immediate priority. Option D, obtaining a CBC, can be done later and is not as crucial as ensuring proper urinary function postoperatively.

4. The mother of a school-age child calls the school to ask when her daughter can return to school after treatment for Pediculosis capitis. What is the nurse’s best response?

• A. When all live lice are eliminated by the treatment
• B. Two weeks after the last treatment
• C. As soon as the itching stops
• D. After the treatment kills all the live lice

Correct answer: D

Rationale: The correct answer is 'After the treatment kills all the live lice.' The child can return to school once all live lice are eliminated to prevent the spread of Pediculosis capitis. This is essential as live lice are highly contagious. Choices A, B, and C are incorrect. Waiting for the itching to stop or for an epidemic to subside does not ensure that all live lice are eradicated, which is crucial to prevent reinfestation and transmission.

5. A client with skin grafts covering full-thickness burns on both arms and legs is scheduled for a dressing change. The client is nervous and requests that the dressing change be skipped this time. What action is most important for the nurse to take?

• A. Explain the importance of regular dressing changes
• B. Administer an anti-anxiety medication
• C. Proceed with the scheduled dressing change
• D. Encourage the client to express any anxieties

Correct answer: A

Rationale: In this situation, the most important action for the nurse to take is to explain the importance of regular dressing changes to the client. By doing so, the nurse can help the client understand the necessity for wound healing and infection prevention. Administering anti-anxiety medication (Choice B) may not address the root cause of the client's anxiety, which is the lack of understanding. Proceeding with the scheduled dressing change (Choice C) without addressing the client's concerns can worsen their anxiety and decrease trust. Encouraging the client to express any anxieties (Choice D) is important but not as crucial as ensuring the client comprehends the rationale behind the dressing change.

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